Helping the brave fight their final battle

CHICAGO • The Vietnam veteran dying of lung cancer was cowering in the corner, emotionally distraught, unwilling to talk to anyone.

When the veteran arrived at the Lebanon VA Medical Center in central Pennsylvania a few days earlier, Dr. Scott Shreve asked if he was troubled by memories of his war experience.

"Yes," replied the veteran, gruffly.

Probing delicately, the palliative care physician asked if the man wanted to share some of his thoughts.

"No," the veteran responded, curtly.

Now, however, surging panic had broken through the patient's emotional defenses. Called by medical staff, several friends rushed to the hospital to help. Eventually, the veteran calmed down and agreed to accept help. He died a week later.

Shreve relates the story as he describes an extensive effort by the Department of Veterans Affairs to improve end-of-life care for veterans. He oversees palliative care at the Lebanon hospital and directs hospice and palliative care nationally for the VA.

The initiative has gained momentum with the recent completion of a new training curriculum, the Education on Palliative and End-of-Life Care for Veterans Project, due to be rolled out to all 153 VA medical centers by the end of 2011. The goal is to educate VA doctors, nurses, chaplains, social workers and psychologists about the best practices for veterans who don't have long to live.

Shreve said a demographic imperative underlies the effort: This year, an estimated 670,000 former soldiers are expected to die of cancer, heart disease, strokes and other ailments. All veterans are entitled to hospice and palliative care under a national directive issued by the VA in 2008.

Recognizing that most veterans die outside VA medical centers, the VA also recently unveiled a partnership with the National Hospice and Palhospice and palliative care at Bay Pines VA Medical Center in St. Petersburg, Fla.

For still other veterans, memories of the violence they inflicted on others during war can be a source of lingering, excruciating guilt, Grassman noted.

In her book, "Peace at Last: Stories of Hope and Healing for Veterans and Their Families" (Vandamere, $19.95), Grassman writes of Sam, a 50-something veteran with terminal colon cancer haunted by images of Viet Cong soldiers he had killed. It was something he had never talked about; only when Sam voiced his need for forgiveness was he able to accept his imminent death, Grassman writes.

Another issue that can emerge at the end of life is the impact of sexual violence in the military, estimated to affect 20 percent of female and 1 percent of male soldiers. When victims of that trauma become dependent and need assistance with intimate activities such as bathing, deeply distressing reactions can be triggered, said Dr. Joshua Hauser, an assistant professor of palliative care at Northwestern University's Feinberg School of Medicine in Chicago.

Some veterans are so invested in stoicism, a grinand-bear-it attitude fostered in the military, they won't admit to pain, impairing caregivers' ability to relieve suffering. Others, who may have once turned to alcohol or drugs to escape the aftereffects of trauma, may fear becoming hooked again on painkillers, said Dr. F. Amos Bailey, director of palliative care at the Birmingham VA Medical Center in Alabama.

Dolores Matulionis, of Stickney, Ill., joined the Women's Army Corps during World War II, training as a nurse, learning to parachute from airplanes and eventually going to Finchhaven, New Guinea, to tend soldiers wounded in the South Pacific.

Her son, Wayne Matulionis, recalled his mother as a tough woman with a can-do attitude who was fond of telling him, "Remember, pal, Rome wasn't built in a day. But I wasn't the boss on that job."

In February, Dolores Matulionis, 87, was admitted to Hines Jr. VA Hospital outside Chicago with advanced congestive heart failure. While in hospice care at the hospital, Matulionis sometimes screamed that snakes and bugs had entered her tent.

On several occasions, when nurses tried to turn her on her side in her hospital bed, she flashed back to parachuting and yelled in fear, "I'm not jumping!"

Eventually, Wayne stopped trying to convince his mom she was an older woman in the hospital, her days numbered.

"She was reliving everything she'd gone through but without the energy of youth," he said.

True to spirit, Matulionis fought with all her might against giving up — until she couldn't any more. She died in July. For many former soldiers, the inability to let go, to stop fighting death, extends to the very last breath.